《靜脈血栓栓塞》

1、危重患者的VTE高危因素和發(fā)病率危重患者的VTE預(yù)防指南和評(píng)估ICU內(nèi)的VTE預(yù)防方法幾個(gè)肺栓塞病例,Covidien | March 23, 2024 | Confidential,2 |,靜脈血栓栓塞癥(VTE)包括深靜脈血栓(DVT)和肺栓塞(PE)。,Definition of Venous Thromboembolism (VTE)靜脈血栓栓塞的定義,Pulmonary Embolism,1C

2、irculation 1996;93:2212; 2N Engl J Med 2004;350:22573Lancet 1997;349:759; 4J Gen Intern Med 2000;26:425,Fatal PE,Asymptomatic PE,Symptomatic DVT,Pulmonary Embolism,4 out of 5 patients will not have any symptoms of throm

3、bosis,Asymptomatic DVT,,,20%,80%,80% ASYMPTOMATICS,Confidential, © Tyco Corporation,Covidien | 23/03/2024 | Confidential,4 |,解決,DVT的后果,靜脈血栓栓塞--,,,,,,,Covidien | 23/03/2024 | Confidential,Confidenti

4、al, © Tyco Corporation,5 |,血流淤滯,血管壁損傷,凝血功能改變,血液循環(huán)流速減慢。血流淤滯同時(shí)發(fā)生在術(shù)中和術(shù)后的臥床時(shí)間,發(fā)生在術(shù)側(cè)肢體的操作過程中會(huì)扭折血管，如全膝或全髖成型術(shù),靜脈血液郁積也會(huì)造成靜脈擴(kuò)張和內(nèi)皮細(xì)胞損傷。,術(shù)后血液中促凝血酶原激酶和纖維蛋白原水平升高，組織損傷處表面凝結(jié)被激活都導(dǎo)致了血液的高凝狀態(tài)。,為什么會(huì)形成DVT？,當(dāng)沒有任何預(yù)防措施時(shí)，DVT在某些?？浦械陌l(fā)生率高于50

5、％,,但是，僅有25％的DVT患者會(huì)表現(xiàn)出癥狀,O’Meara et al. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty. ORTHOPEDICS.,深靜脈血栓流行病學(xué)（外科各專業(yè)）,,臨床路徑推薦,Risk factors for VTE,Active cancer or cancer treatmentAge over 60 yearsCr

6、itical care admissionDehydrationKnown thrombophiliasObesity (body mass index [BMI] over 30 kg/m2)One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory patholog

7、ies; acute infectious diseases; inflammatory conditions)Personal history or first-degree relative with a history of VTEUse of hormone replacement therapyUse of oestrogen-containing contraceptive therapyVaricose veins

8、 with phlebitisFor women who are pregnant or have given birth within the previous 6 weeks,Regard medical patients as being at increased risk of VTE if they:,have had or are expected to have significantly reduced mobilit

9、y for 3 days or more orare expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors,Regard surgical patients and patients with trauma as being at increased risk

10、of VTE if they meet one of the following criteria:,surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limbacute surgical adm

11、ission with inflammatory or intra-abdominal conditionexpected significant reduction in mobilityone or more of the risk factors,Risk factors for bleeding,Active bleedingAcquired bleeding disorders (such as acute liver

12、 failure)Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio [INR] higher than 2)Lumbar puncture/epidural/spinal anaesthesia expected within the

13、 next 12 hoursLumbar puncture/epidural/spinal anaesthesia within the previous 4 hoursAcute strokeThrombocytopenia (platelets less than 75 x 109/l)Uncontrolled systolic hypertension (230/120 mmHg or higher)Untreated

14、inherited bleeding disorders (such as haemophilia and von Willebrand's disease),Pharmacological VTE prophylaxis,For example:General medical patientsfondaparinux sodiumlow molecular weight heparin (LMWH)unfractio

15、nated heparin (UFH) (for patients with renal failure).Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VT

16、E,Patients with stroke,Patients with cancerPatients with central venous cathetersPatients in palliative careAll surgeryCardiac surgeryGastrointestinal, gynaecological, thoracic and urological,物理預(yù)防在ICU的優(yōu)勢(shì)： ICU患者剛?cè)朐?/p>

17、時(shí)大多具有消化道應(yīng)激性潰瘍出血風(fēng)險(xiǎn) 部分重癥患者有凝血功能障礙、腎功能障礙 ICU患者本身情況復(fù)雜，用藥難以掌握,出血并發(fā)癥,物理預(yù)防：ICU患者不可或缺,18 |,靜脈瓣后清除,SCD壓力系統(tǒng)提供最佳連續(xù)梯度壓力模式使股靜脈血流速度達(dá)到最大“理想的壓力模式為踝部35mmHg，小腿30mmHg，大腿20mmHg?！薄?然而，由于廣泛存在的個(gè)體差異，這個(gè)壓力可以稍微增加（例如45，40，30mmHg）?！?Covidien

18、 | 23/03/2024 | Confidential,Confidential, © Tyco Corporation,21 |,Nicolaides et al. Intermittent Sequential Pneumatic Compression of the Legs in the Prevention of Venous Stasis and Postoperative Deep Veno

19、us Thrombosis, Surgery 1980: 87: 69-76,大腿小腿踝部,壓力mmHg,SCD壓力系統(tǒng)在股靜脈血液清除方面，速度明顯優(yōu)于小腿、單一壓力系統(tǒng). “SCD 可以在很短的時(shí)間內(nèi)清空靜脈瓣后淤滯的血液，而如果只對(duì)小腿施壓,相應(yīng)的染色物質(zhì)會(huì)停留長(zhǎng)時(shí)間?！保ㄐ⊥?、單一壓力系統(tǒng)）,Confidential, © Tyco Corporation,Covidien | 23/03/2024

20、 | Confidential,Mittleman et al. Effectiveness of Leg Compression in Preventing Venous Stasis. The American Journal of Surgery 1982; 144:611-613,,Covidien | 23/03/2024 | Confidential,Confidential, © Tyco C

21、orporation,24 |,靜脈再充盈檢測(cè),Covidien | 23/03/2024 | Confidential,Confidential, © Tyco Corporation,25 |,血液移動(dòng)總量,相同的情況在靜脈曲張的病人中，仰臥位增加71.9%，半臥位增加77.9%，坐姿時(shí)增加55.7%?！?Kakkos et al. Improved hemodynamic effectivenes

22、s and associated clinical correlations of a new intermittent pneumatic comporession system in patients with chronic venous insufficiency. Journal of Vascular Surgery, Nov 2001; Vol 34, No. 5, 915-922,,主機(jī)連接管腿套/足套 （

23、45mmHg, 40mmHg,30mmHg） (130mmHg),腿部壓力：預(yù)防深靜脈血栓癥和肺部栓塞足部壓力：1.　增強(qiáng)血液循環(huán)2.　預(yù)防深靜脈血栓癥3.　急性水腫4.　慢性水腫5.　外傷或外科手術(shù)引發(fā)的四肢疼痛6.　腿部潰瘍7.　靜脈郁積/靜脈功能障礙,腿部壓力：任何有可能防礙充氣壓力帶作用的腿局部情況，例如：（a）皮炎，（b）靜脈結(jié)扎（在手術(shù)后即刻），（c）壞疽，或者（d）剛做完皮膚移植手術(shù)嚴(yán)重的

24、動(dòng)脈硬化癥或其它缺血性血管病腿部大范圍水腫或由充血性心力衰竭引發(fā)的肺部水腫腿部嚴(yán)重畸形疑似已出現(xiàn)深靜脈血栓癥足部壓力：增強(qiáng)回流心臟的流速會(huì)有害的情況下充血性心力衰竭已出現(xiàn)深靜脈血栓癥、血栓(性)靜脈炎或肺部栓塞對(duì)于手足部存在感染或感覺遲鈍情況的患者，使用時(shí)必須非常小心,“盡管梯度壓力彈力襪外表看上去很簡(jiǎn)單，但是其中的設(shè)計(jì)卻很復(fù)雜，對(duì)于技術(shù)細(xì)節(jié)的關(guān)注可以得到有效的預(yù)防方法。”,Covidien | 23/03/2

25、024 | Confidential,Confidential, © Tyco Corporation,31 |,J.Caprini MD.,,Covidien | 23/03/2024 | Confidential,Confidential, © Tyco Corporation,32 |,,T.E.D. Antiembolism StockingT.E.D. 抗血栓壓力帶,Oth

26、er Antiembolism Stocking其它抗血栓壓力帶,圓周鑲嵌編織法單向水平伸展確?？寡?壓力帶的固定,圓周編織提供單向伸展確保壓力分布正確定位,垂直伸展使尼龍襪滑落,Using the Kendall TED stockings which apply the correct pressure profile, Holford (B.M.J. 1976,2 969-970) showed that TED st

27、ockings reduced the incidence of deep vein thrombosis in surgical patients from 49% to 23% and concluded”…improper design, construction or fit can be dangerous.”,垂直伸展使尼龍襪滑落,7位半臥位自愿者，5個(gè)帶水壓計(jì)的可充氣套觀察血流速度 確定理想的壓力分布18，14，8，10

28、，8mmHg相對(duì)與基線，平均股靜脈血流速度增加138.4%,Covidien | 23/03/2024 | Confidential,Confidential, © Tyco Corporation,33 |,100+文獻(xiàn)證明SCD和TED的有效性,,Woolson et al. Journal of Bone & Joint Surgery 1991 (全髖關(guān)節(jié)置換術(shù)病人)

29、“我們相信在術(shù)中和術(shù)后使用間歇式充氣壓力裝置（無抗凝劑），是有效，安全和便利的?！?Covidien | 23/03/2024 | Confidential,Confidential, © Tyco Corporation,35 |,亞洲人群髖關(guān)節(jié)手術(shù)后采用非藥物預(yù)防后無癥狀的深靜脈血栓的自然過程,術(shù)后沒有患者發(fā)展致命有癥狀的肺栓塞，或近端深靜脈血栓。但是9個(gè)患者（5%）發(fā)展成遠(yuǎn)端深靜脈血栓，沒

30、有術(shù)前相關(guān)危險(xiǎn)因子。這9位患者術(shù)后緊密隨訪未用抗凝劑治療，6個(gè)月后所有的血栓消失未發(fā)展成肺栓塞或血栓性靜脈炎,靜脈血栓物理預(yù)防全方位解決方案,AVI 動(dòng)靜脈脈沖系統(tǒng),SCD氣動(dòng)歇式壓力裝置,TED抗血栓壓力帶,Case 1：lucky patient，lucky doctor,Female，63yearsRecurrent syncopeSpO2 60%~70%HypotensionECG：RBBBD-Dimer：2

31、.386ug/mlCTA：肺動(dòng)脈主干及雙肺動(dòng)脈多發(fā)性栓塞,,rt-PA 50mg Day-2:ECG normal;有嘔吐表現(xiàn)CT小腦半球少量出血保守治愈,Case 2： Brave doctor,,第一次尿激酶溶栓 150萬u一次VD，復(fù)查肺CTA如上圖，機(jī)械通氣氧合改善不滿意，未能脫機(jī)尿激酶 二次溶栓4400u/Kg/h,共十二小時(shí)緩解，氧合改善，出院回當(dāng)?shù)蒯t(yī)院復(fù)查CTA肺動(dòng)脈血栓消失,Case 3

32、 Looking for living chance in a given specific time slot,中年男性，泌尿外科腎臟手術(shù)后8天，突發(fā)氣急、大汗，血壓下降，轉(zhuǎn)入ICU尿激酶溶栓150萬u一次VD血壓回升、血氧改善超聲監(jiān)測(cè)腹腔積液量有增加，血漿、止血藥物保守治愈,Case 4：no CTPA，no treatment？ Don't hesitate any

33、 more ！,老年女性，右下肢骨折石膏固定后20天，起床上廁所后突發(fā)休克伴嚴(yán)重低氧血癥急診考慮休克原因待查，感染性休克？收ICU進(jìn)ICU后ECG ：SⅠTⅢ尿激酶溶栓120萬u一次VD，氣急缺氧癥狀緩解，血壓回升不滿意，追加4400u/Kg/h,共8小時(shí)，無出血并發(fā)癥，血管活性藥物撤除。正規(guī)抗凝治療治愈出院,Case 5 when death became an accomplished fact,Male,67yea

34、rs,2011-10-18因血尿入院保留導(dǎo)尿，持續(xù)膀胱沖洗2011-10-24 2:30突發(fā)胸悶氣急、煩躁不安、全身冷汗，血壓下降。搶救無效于5:00死亡尸體解剖,大體：尸長(zhǎng)166cm，發(fā)育良好，營(yíng)養(yǎng)正常。頭顱五官無異常。鋸開顱腔，腦實(shí)質(zhì)未見異常。胸骨位于第三四肋間有骨折線，雙胸腔少量淡血性積液。肺：右肺部分纖維性粘連，雙肺飽滿。心包腔：40ml淡紅色清亮液體心臟：右心肺動(dòng)脈開口處可見血栓成分，阻塞左右肺動(dòng)脈主干，呈騎